HMHB Emergency Resource Request Form for Affected Families
Aloha, this form is intended for families impacted by the recent Hurricane Lowell, with preference to Kauaʻi families. Please complete the information below to request assistance with essential needs. Healthy Mothers Healthy Babies Coalition of Hawaiʻi will review your request and reach out with available support as soon as possible.
'Ohana Name - Point of Contact
Phone Number *Not shared publicly*
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address. *Not shared publicly.*
*
example@example.com
Number of people in household. Ex. 2 adults, 2 keiki. Please include the age and gender of each child.
Is anyone in the household currently pregnant?
Yes
No
What island are you on?
Oahu
Maui
Moloka'i
Lana'i
Hawai'i Island
Kaua'i
Niʻihau
What is the address of the impacted property?
How were you impacted by the storm? (select all that applies)
Displaced from home
Severe damage to home/property
Minor damage to home/property
Damage from Kona Lows
Damage from Lala
Damage from Lowell
Damage to vehicle
Other
Explain why assistance is needed and where damage took place. This information is being collected solely for funding purposes. Please advise if you received help from us in the past.
What are you in need of?
Diapers
Car Seats (replacement due to storm damage, photo requested)
Strollers (replacement due to storm damage, photo requested)
Cribs/Pack-n-Play (replacement due to storm damage, photo requested)
Breastfeeding / Infant feeding supplies
Other
If you selected diapers, medical support, or "other", please provide sizes and any additional information below:
Shared by *For verification only. Not shared publicly*:
We are the displaced 'ohana
I know this 'ohana and personally vouch for them
Sharing but haven't personally verified
HMHB Staff Submitted
Name (HMHB staff or person vouching for family)
Help us verify the severity of your need. Please upload photos here (home, car seats, cribs, etc). *Not shared publicly.*
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